Management of Patients With Bicuspid Aortic Valve Disease

  • Todd L. Kiefer
  • Andrew Wang
  • G. Chad Hughes
  • Thomas M. BashoreEmail author
Valvular, Myocardial, Pericardial, and Cardiopulmonary Diseases (Patrick O’Gara and Akshay Desai, Section Editors)

Opinion statement

Our approach to the management of the patient with a bicuspid aortic valve (BAV) takes several factors into consideration. First, is the dysfunction of the valve due to aortic stenosis (AS), aortic regurgitation (AR), or a combination of stenosis and regurgitation, and what is the severity? Next, is there aortic dilation in any of the regions (sinuses of Valsalva, sinotubular junction, tubular ascending aorta, or transverse arch) discussed in this article. In general, we follow patients with a BAV and moderate valve dysfunction (AS or AR) with yearly surveillance transthoracic echocardiography for left ventricular function, jet velocity, gradient, and valve area with AS, whereas left ventricular (LV) function and LV dimensions are monitored for patients with AR. In addition, yearly clinical evaluation for change in symptom status or functional capacity is critical. More recently, we have utilized NT-pro BNP levels to help assess patients, particularly those in whom the anatomic severity does not match the clinical symptoms (ie, the valve severity appears mild but the patient is complaining of symptoms or the valve severity seems significant but no symptoms are noted). All patients with a bicuspid valve should have evaluation of the aorta with a MRI or CT angiography at some point, as 50% of BAV patients have aortic root involvement. At our institution, cardiac MRI is preferred unless there is a contraindication, particularly in younger patients, given the cumulative radiation exposure from surveillance CT scans. Cardiac MRI also provides the added benefit of information regarding LV function, LV dimensions, and assessment of valve stenosis/regurgitation severity, thus obviating the need for echocardiographic data in those being followed with serial cardiac MRI. For those with no aortic dilatation, we tend to use only echocardiography for follow-up. For patients with mild aortic dilation, surveillance aortic imaging is usually performed every 3–5 years. However, for those with greater degrees of aortic dilation (aortic diameters >4.0 cm) or notable interval change in dimensions, then aortic imaging every year is conducted. For young adult patients with isolated aortic stenosis, balloon aortic valvuloplasty is often an effective and temporizing treatment option. In older patients with aortic stenosis or those with AR, aortic valve replacement, with or without a surgery on the aorta depending on whether concomitant dilation (aortic diameter >4.5 cm) of the aorta is present, is the preferred management strategy. In a few patients, surgery on the aortic alone may be indicated if the maximal diameter exceeds 5.0 cm.


Aortic Stenosis Infective Endocarditis Aortic Root Aortic Valve Replacement Aortic Regurgitation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



T.L Kiefer: none; A. Wang has received grants to his institution from Abbott Vascular and Edwards Lifesciences; G.C. Hughes: none; T.M. Bashore: none.

References and recommended reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    O’Malley CD, Saunders CM. Leonardo da Vinci on the human body. New York: H. Wolff Company; 1952.Google Scholar
  2. 2.
    Movahed MR, Hepner AD, Ahmadi-Kashani M. Echocardiographic prevalence of bicuspid aortic valve in the population. Heart Lung Circ. 2006;15(5):297–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Nistri S, Basso C, Marzari C, Mormino P, Thiene G. Frequency of bicuspid aortic valve in young male conscripts by echocardiogram. Am J Cardiol. 2005;96(5):718–21.PubMedCrossRefGoogle Scholar
  4. 4.
    Jashari R, Van Hoeck B, Goffin Y, Vanderkelen A. The incidence of congenital bicuspid or bileaflet and quadricuspid or quadrileaflet arterial valves in 3,861 donor hearts in the European Homograft Bank. J Heart Valve Dis. 2009;18(3):337–44.PubMedGoogle Scholar
  5. 5.
    Tutar E, Ekici F, Atalay S, Nacar N. The prevalence of bicuspid aortic valve in newborns by echocardiographic screening. Am Heart J. 2005;150(3):513–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Roos-Hesselink JW, Scholzel BE, Heijdra RJ, Spitaels SE, Meijboom FJ, Boersma E, et al. Aortic valve and aortic arch pathology after coarctation repair. Heart. 2003;89(9):1074–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Sybert VP. Cardiovascular malformations and complications in Turner syndrome. Pediatrics. 1998;101(1):E11.PubMedCrossRefGoogle Scholar
  8. 8.
    Miller MJ, Geffner ME, Lippe BM, Itami RM, Kaplan SA, DiSessa TG, et al. Echocardiography reveals a high incidence of bicuspid aortic valve in Turner syndrome. J Pediatr. 1983;102(1):47–50.PubMedCrossRefGoogle Scholar
  9. 9.
    Roberts WC, Morrow AG, Braunwald E. Complete interruption of the aortic arch. Circulation. 1962;26:39–59.PubMedCrossRefGoogle Scholar
  10. 10.
    Sugayama SM, Moises RL, Wagenfur J, Ikari NM, Abe KT, Leone C, et al. Williams-Beuren syndrome: cardiovascular abnormalities in 20 patients diagnosed with fluorescence in situ hybridization. Arq Bras Cardiol. 2003;81(5):462–73.PubMedCrossRefGoogle Scholar
  11. 11.
    Lerer PK, Edwards WD. Coronary arterial anatomy in bicuspid aortic valve. Necropsy study of 100 hearts. Br Heart J. 1981;45(2):142–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Johnson AD, Detwiler JH, Higgins CB. Left coronary artery anatomy in patients with bicuspid aortic valves. Br Heart J. 1978;40(5):489–93.PubMedCrossRefGoogle Scholar
  13. 13.
    McKusick VA. Association of congenital bicuspid aortic valve and erdheim’s cystic medial necrosis. Lancet. 1972;1(7758):1026–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Gale AN, McKusick VA, Hutchins GM, Gott VL. Familial congenital bicuspid aortic valve: secondary calcific aortic stenosis and aortic aneurysm. Chest. 1977;72(5):668–70.PubMedCrossRefGoogle Scholar
  15. 15.
    Godden DJ, Sandhu PS, Kerr F. Stenosed bicuspid aortic valves in twins. Eur Heart J. 1987;8(3):316–8.PubMedGoogle Scholar
  16. 16.
    McDonald K, Maurer BJ. Familial aortic valve disease: evidence for a genetic influence? Eur Heart J. 1989;10(7):676–7.PubMedGoogle Scholar
  17. 17.
    Huntington K, Hunter AG, Chan KL. A prospective study to assess the frequency of familial clustering of congenital bicuspid aortic valve. J Am Coll Cardiol. 1997;30(7):1809–12.PubMedCrossRefGoogle Scholar
  18. 18.
    • Biner S, Rafique AM, Ray I, Cuk O, Siegel RJ, Tolstrup K: Aortopathy is prevalent in relatives of bicuspid aortic valve patients. J Am Coll Cardiol 2009, 53(24):2288–2295. PubMedCrossRefGoogle Scholar
  19. 19.
    Garg V, Muth AN, Ransom JF, Schluterman MK, Barnes R, King IN, et al. Mutations in NOTCH1 cause aortic valve disease. Nature. 2005;437(7056):270–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Mohamed SA, Hanke T, Schlueter C, Bullerdiek J, Sievers HH. Ubiquitin fusion degradation 1-like gene dysregulation in bicuspid aortic valve. J Thorac Cardiovasc Surg. 2005;130(6):1531–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Martin LJ, Ramachandran V, Cripe LH, Hinton RB, Andelfinger G, Tabangin M, et al. Evidence in favor of linkage to human chromosomal regions 18q, 5q and 13q for bicuspid aortic valve and associated cardiovascular malformations. Hum Genet. 2007;121(2):275–84.PubMedCrossRefGoogle Scholar
  22. 22.
    Mohamed SA, Aherrahrou Z, Liptau H, Erasmi AW, Hagemann C, Wrobel S, et al. Novel missense mutations (p.T596M and p.P1797H) in NOTCH1 in patients with bicuspid aortic valve. Biochem Biophys Res Commun. 2006;345(4):1460–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Roberts WC. The congenitally bicuspid aortic valve. A study of 85 autopsy cases. Am J Cardiol. 1970;26(1):72–83.PubMedCrossRefGoogle Scholar
  24. 24.
    Sabet HY, Edwards WD, Tazelaar HD, Daly RC. Congenitally bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases. Mayo Clin Proc. 1999;74(1):14–26.PubMedCrossRefGoogle Scholar
  25. 25.
    Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007;133(5):1226–33.PubMedCrossRefGoogle Scholar
  26. 26.
    Fernandes SM, Sanders SP, Khairy P, Jenkins KJ, Gauvreau K, Lang P, et al. Morphology of bicuspid aortic valve in children and adolescents. J Am Coll Cardiol. 2004;44(8):1648–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Schaefer BM, Lewin MB, Stout KK, Gill E, Prueitt A, Byers PH, et al. The bicuspid aortic valve: an integrated phenotypic classification of leaflet morphology and aortic root shape. Heart. 2008;94(12):1634–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Russo CF, Cannata A, Lanfranconi M, Vitali E, Garatti A, Bonacina E. Is aortic wall degeneration related to bicuspid aortic valve anatomy in patients with valvular disease? J Thorac Cardiovasc Surg. 2008;136(4):937–42.PubMedCrossRefGoogle Scholar
  29. 29.
    Fernandes SM, Khairy P, Sanders SP, Colan SD. Bicuspid aortic valve morphology and interventions in the young. J Am Coll Cardiol. 2007;49(22):2211–4.PubMedCrossRefGoogle Scholar
  30. 30.
    •• Tzemos N, Therrien J, Yip J, Thanassoulis G, Tremblay S, Jamorski MT, Webb GD, Siu SC: Outcomes in adults with bicuspid aortic valves. JAMA 2008, 300(11):1317–1325.PubMedCrossRefGoogle Scholar
  31. 31.
    Brandenburg Jr RO, Tajik AJ, Edwards WD, Reeder GS, Shub C, Seward JB. Accuracy of 2-dimensional echocardiographic diagnosis of congenitally bicuspid aortic valve: echocardiographic-anatomic correlation in 115 patients. Am J Cardiol. 1983;51(9):1469–73.PubMedCrossRefGoogle Scholar
  32. 32.
    Espinal M, Fuisz AR, Nanda NC, Aaluri SR, Mukhtar O, Sekar PC. Sensitivity and specificity of transesophageal echocardiography for determination of aortic valve morphology. Am Heart J. 2000;139(6):1071–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Tirrito SJ, Kerut EK. How not to miss a bicuspid aortic valve in the echocardiography laboratory. Echocardiography. 2005;22(1):53–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(23):e1–121.PubMedCrossRefGoogle Scholar
  35. 35.
    Gleeson TG, Mwangi I, Horgan SJ, Cradock A, Fitzpatrick P, Murray JG. Steady-state free-precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves. J Magn Reson Imaging. 2008;28(4):873–8.PubMedCrossRefGoogle Scholar
  36. 36.
    •• Michelena HI, Desjardins VA, Avierinos JF, Russo A, Nkomo VT, Sundt TM, Pellikka PA, Tajik AJ, Enriquez-Sarano M: Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation 2008, 117(21):2776–2784.PubMedCrossRefGoogle Scholar
  37. 37.
    Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation. 2005;111(7):920–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Subramanian R, Olson LJ, Edwards WD. Surgical pathology of pure aortic stenosis: a study of 374 cases. Mayo Clin Proc. 1984;59(10):683–90.PubMedGoogle Scholar
  39. 39.
    Donal E, Novaro GM, Deserrano D, Popovic ZB, Greenberg NL, Richards KE, et al. Planimetric assessment of anatomic valve area overestimates effective orifice area in bicuspid aortic stenosis. J Am Soc Echocardiogr. 2005;18(12):1392–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Bonow RO, Carabello BA, Chatterjee K, de Leon Jr AC, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1–142.PubMedCrossRefGoogle Scholar
  41. 41.
    Delgado V, Tops LF, Schuijf JD, van der Kley F, van de Veire NR, Schalij MJ, et al. Successful deployment of a transcatheter aortic valve in bicuspid aortic stenosis: role of imaging with multislice computed tomography. Circ Cardiovasc Imaging. 2009;2(2):e12–13.PubMedCrossRefGoogle Scholar
  42. 42.
    Wijesinghe N, Ye J, Rodes-Cabau J, Cheung A, Velianou JL, Natarajan MK, et al. Transcatheter aortic valve implantation in patients with bicuspid aortic valve stenosis. JACC Cardiovasc Interv. 2010;3(11):1122–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Roberts WC, Morrow AG, McIntosh CL, Jones M, Epstein SE. Congenitally bicuspid aortic valve causing severe, pure aortic regurgitation without superimposed infective endocarditis. Analysis of 13 patients requiring aortic valve replacement. Am J Cardiol. 1981;47(2):206–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Olson LJ, Subramanian R, Edwards WD. Surgical pathology of pure aortic insufficiency: a study of 225 cases. Mayo Clin Proc. 1984;59(12):835–41.PubMedGoogle Scholar
  45. 45.
    Lewin MB, Otto CM. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circulation. 2005;111(7):832–4.PubMedCrossRefGoogle Scholar
  46. 46.
    Nataatmadja M, West M, West J, Summers K, Walker P, Nagata M, et al. Abnormal extracellular matrix protein transport associated with increased apoptosis of vascular smooth muscle cells in marfan syndrome and bicuspid aortic valve thoracic aortic aneurysm. Circulation. 2003;108 Suppl 1:II329–34.PubMedGoogle Scholar
  47. 47.
    Vallely MP, Semsarian C, Bannon PG. Management of the ascending aorta in patients with bicuspid aortic valve disease. Heart Lung Circ. 2008;17(5):357–63.PubMedCrossRefGoogle Scholar
  48. 48.
    Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz 3rd HC. Angiotensin II blockade and aortic-root dilation in Marfan’s syndrome. N Engl J Med. 2008;358(26):2787–95.PubMedCrossRefGoogle Scholar
  49. 49.
    Gomez D, Coyet A, Ollivier V, Jeunemaitre X, Jondeau G, Michel JB, et al. Epigenetic control of vascular smooth muscle cells in Marfan and non-Marfan thoracic aortic aneurysms. Cardiovasc Res. 2011;89(2):446–56.PubMedCrossRefGoogle Scholar
  50. 50.
    Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation. 2002;106(8):900–4.PubMedCrossRefGoogle Scholar
  51. 51.
    Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey Jr DE. Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA et al: 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121(13):e266–369.PubMedCrossRefGoogle Scholar
  52. 52.
    Tadros TM, Klein MD, Shapira OM. Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications. Circulation. 2009;119(6):880–90.PubMedCrossRefGoogle Scholar
  53. 53.
    McDonald ML, Smedira NG, Blackstone EH, Grimm RA, Lytle BW, Cosgrove DM. Reduced survival in women after valve surgery for aortic regurgitation: effect of aortic enlargement and late aortic rupture. J Thorac Cardiovasc Surg. 2000;119(6):1205–12.PubMedCrossRefGoogle Scholar
  54. 54.
    El-Hamamsy I, Yacoub MH. A measured approach to managing the aortic root in patients with bicuspid aortic valve disease. Curr Cardiol Rep. 2009;11(2):94–100.PubMedCrossRefGoogle Scholar
  55. 55.
    Edwards WD, Leaf DS, Edwards JE. Dissecting aortic aneurysm associated with congenital bicuspid aortic valve. Circulation. 1978;57(5):1022–5.PubMedGoogle Scholar
  56. 56.
    Roberts CS, Roberts WC. Dissection of the aorta associated with congenital malformation of the aortic valve. J Am Coll Cardiol. 1991;17(3):712–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 1984;53(6):849–55.PubMedCrossRefGoogle Scholar
  58. 58.
    • Fazel SS, Mallidi HR, Lee RS, Sheehan MP, Liang D, Fleischman D, Herfkens R, Mitchell RS, Miller DC: The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch. J Thorac Cardiovasc Surg 2008, 135(4):901–907, 907 e901-902.PubMedCrossRefGoogle Scholar
  59. 59.
    Ferencik M, Pape LA. Changes in size of ascending aorta and aortic valve function with time in patients with congenitally bicuspid aortic valves. Am J Cardiol. 2003;92(1):43–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Yasuda H, Nakatani S, Stugaard M, Tsujita-Kuroda Y, Bando K, Kobayashi J. Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve. Circulation. 2003;108:II291–4.PubMedCrossRefGoogle Scholar
  61. 61.
    Loscalzo ML, Goh DL, Loeys B, Kent KC, Spevak PJ, Dietz HC. Familial thoracic aortic dilation and bicommissural aortic valve: a prospective analysis of natural history and inheritance. Am J Med Genet A. 2007;143A(17):1960–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Borger MA, Preston M, Ivanov J, Fedak PW, Davierwala P, Armstrong S, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg. 2004;128(5):677–83.PubMedGoogle Scholar
  63. 63.
    Cameron DE, Vricella LA. What is the proper place of the Ross procedure in our modern armamentarium? Curr Cardiol Rep. 2007;9(2):93–8.PubMedCrossRefGoogle Scholar
  64. 64.
    de Sa M, Moshkovitz Y, Butany J, David TE. Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the ross procedure. J Thorac Cardiovasc Surg. 1999;118(4):588–94.PubMedCrossRefGoogle Scholar
  65. 65.
    Luciani GB, Casali G, Favaro A, Prioli MA, Barozzi L, Santini F. Fate of the aortic root late after Ross operation. Circulation. 2003;108 Suppl 1:II61–7.PubMedGoogle Scholar
  66. 66.
    David TE, Woo A, Armstrong S, Maganti M. When is the Ross operation a good option to treat aortic valve disease? J Thorac Cardiovasc Surg. 2010;139(1):68–73. discussion 73–65.PubMedCrossRefGoogle Scholar
  67. 67.
    Ryan WH, Prince SL, Culica D, Herbert MA. The Ross procedure performed for aortic insufficiency is associated with increased autograft reoperation. Anna thorac surg. 2011;91(1):64–9. discussion 69–70.CrossRefGoogle Scholar
  68. 68.
    Borger MA, David TE. Management of the valve and ascending aorta in adults with bicuspid aortic valve disease. Semin Thorac Cardiovasc Surg. 2005;17(2):143–7.PubMedCrossRefGoogle Scholar
  69. 69.
    El Khoury G, Vanoverschelde JL, Glineur D, Pierard F, Verhelst RR, Rubay J, et al. Repair of bicuspid aortic valves in patients with aortic regurgitation. Circulation. 2006;114(1 Suppl):I610–1616.PubMedGoogle Scholar
  70. 70.
    Davierwala PM, David TE, Armstrong S, Ivanov J. Aortic valve repair versus replacement in bicuspid aortic valve disease. J Heart Valve Dis. 2003;12(6):679–86. discussion 686.PubMedGoogle Scholar
  71. 71.
    Aicher D, Fries R, Rodionycheva S, Schmidt K, Langer F, Schafers HJ. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg. 2010;37(1):127–32.PubMedCrossRefGoogle Scholar
  72. 72.
    Ashikhmina E, Sundt 3rd TM, Dearani JA, Connolly HM, Li Z, Schaff HV. Repair of the bicuspid aortic valve: a viable alternative to replacement with a bioprosthesis. J Thorac Cardiovasc Surg. 2010;139(6):1395–401.PubMedCrossRefGoogle Scholar
  73. 73.
    Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968;23(4):338–9.PubMedCrossRefGoogle Scholar
  74. 74.
    Etz CD, Homann TM, Silovitz D, Spielvogel D, Bodian CA, Luehr M, et al. Long-term survival after the Bentall procedure in 206 patients with bicuspid aortic valve. Ann Thorac Surg. 2007;84(4):1186–93. discussion 1193–1184.PubMedCrossRefGoogle Scholar
  75. 75.
    Osler W. The bicuspid condition of the aortic valves. Trans Ass Amer Physicians. 1886;2:185–92.Google Scholar
  76. 76.
    Braverman AC, Guven H, Beardslee MA, Makan M, Kates AM, Moon MR. The bicuspid aortic valve. Curr Probl Cardiol. 2005;30(9):470–522.PubMedCrossRefGoogle Scholar
  77. 77.
    Ward C. Clinical significance of the bicuspid aortic valve. Heart. 2000;83(1):81–5.PubMedCrossRefGoogle Scholar
  78. 78.
    Kahveci G, Bayrak F, Pala S, Mutlu B. Impact of bicuspid aortic valve on complications and death in infective endocarditis of native aortic valves. Tex Heart Inst J. 2009;36(2):111–6.PubMedGoogle Scholar
  79. 79.
    Lamas CC, Eykyn SJ. Bicuspid aortic valve–A silent danger: analysis of 50 cases of infective endocarditis. Clin Infect Dis. 2000;30(2):336–41.PubMedCrossRefGoogle Scholar
  80. 80.
    Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. 2005;45(8):1334–40.PubMedCrossRefGoogle Scholar
  81. 81.
    Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104(5):515–21.PubMedCrossRefGoogle Scholar
  82. 82.
    Elkayam U, Bitar F. Valvular heart disease and pregnancy part I: native valves. J Am Coll Cardiol. 2005;46(2):223–30.PubMedCrossRefGoogle Scholar
  83. 83.
    Immer FF, Bansi AG, Immer-Bansi AS, McDougall J, Zehr KJ, Schaff HV, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003;76(1):309–14.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Todd L. Kiefer
    • 1
  • Andrew Wang
    • 1
  • G. Chad Hughes
    • 1
  • Thomas M. Bashore
    • 1
    Email author
  1. 1.Duke Medical CenterDurhamUSA

Personalised recommendations